1. A 35-year-old female presented with generalized weakness for 2 years, increased urination frequency and excessive thirst for the same duration. 2. On examination, she was found to have mild anemia, koilonychia, hyperpigmented skin lesions, enlarged thyroid gland, and hypertensive retinopathy. 3. Laboratory tests showed TSH of 40.5 mIU/ml, positive thyroid antibodies, HbA1c of 13.7%, elevated lipids, and signs of kidney involvement.

1. GOOD
MORNING

3. Dr. Showrab Biswas
Dr. Md. Jaki yamani abirDr. Md. Jaki yamani abir
Resident Phase – A
Hematology
Department of Endocrinology

4. Mrs. X
Female
35 years
Housewife

5.  Generalized weakness for 2 years
 Increassed frequency of micturation &
excessive thurst for same duration

6. Generalized Weakness
 for 2 years
 progressive in nature
 no diurnal variation
 more marked for last 2 months
 hampered her daily activity

7. Increased frequency of micturation &
excessive thrist
 About 10-12 times in a day including 3-4 times
at night which hampered her sleeping
 Associated with increased thirst more marked
at night
 No h/o burning sensation of micturation
 No h/o leg swelling

8.  Weight loss- 18 kg( last 3 years)
 Hypertension for 1 year
 Visited a physician & diagnosed as DM &
reffered to BSMMU
 No h/o Abdominal pain, Bone pain, Chronic
Diarrhoea, loss of consciousness, no h/o D& C

9.  Age of menarche - at 12 years
 Amenorrhea for last 10 years(associated with
back pain, body ache, tingling sensation & hot
flush )

10.  NVD ,NO APH & PPH
 No h/o lactational failure
 Occasional intake of Tobacco leaf with betel nuts
 Education- Class 8

11.  Married for 22 years
 She has one daughter (now 18 yrs of old) & she
is in good health
 She has 3 sisters & 2 of them suffering from
DM (on OHA )

12.  Losartan potassium-50 mg
for 1 year
 Hydrochlorothiazide-12.5mg
 Took OCP for 6 months 16 years back

13.  She was immunized as per EPI schedule.

14.  PR - 82 beats/min ,Regular
 BP - 110 / 70 mmHg
 Temp- 98.4 F
 RR- 16 br/min

15. Anaemia- mild
Koilonychia – present
Weight – 42 kg
Height – 160 cm
BMI – 16.40 kg/m2

16.  Skin – * Hyperpigmented scaly plaque
present over dorsum of the foot ,lateral side of
left arm & also some well circumscribed
hyperpigmented patch over neck , abdomen,
axilla, groin.
* Hypopigmented area present inner
surface of both lips

20. Thyroid gland –
Diffusely enlarged
Firm
Non tender
No bruit

21. Abdominal examination:
There is a large well
circumscribed patch over the lower & mid
point of the abdomen
No organomegaly.

22.  Motor function and reflexes: Intact
 Sensory: All modalities of sensations are intact
 Cranial nerve: Intact
Ophthalmoscopy
Grade-2 hypertensive retinopathy
No diabetic retinopathy
Other systemic examinations reveal no
abnormality

23. Test Name 02/02/2013
Hb 13.6g/dl
ESR 20 mm in1st
hr
Total Count
RBC 3.63M/µl
Platelets 320000/mm3
WBC
PBF
9500/mm3 (N-63%, L-30%)
Non specific finding
(26/05/13) –FBS-
2 hr. after 75 gm glucose –
23.1 mmol/L
32.7 mmol/L
Urine for ketone Body Negative
04/06/13 HbA1c 13.7 %
Urine RME
Spot urinary micro albumin
Pus cell- 0-2/HPF ,Protein -Nil
5o mg/l (< 20 mg/L)

24. 26/05/13
 Fasting Lipid Profile
Choles(T): 298 mg/dl
HDL : 45.1 mg/dl
LDL : 92.9 mg/dl
TG : 800 mg/dl
 04/06/13 : SGPT : 43 U/L
 30/05/13 : Serum Electrolyte:
Na – 134.6 mmol/l
K -- 3.49 mmol/l
Cl – 94.8 mmol/l

25.  05/06/13 –
TSH – 40.5 microIU/ml (0. 35-5.5)
FT4 – 0.70 ng/dl (0.8-1.8)
 09/06/13
Anti Thyrogloblulin Ab -<20.0 IU/ml(upto40)
Anti Thyroid peroxidase Ab – 681 IU/ml (upto 35)

26.  05/06/13 :
FSH - 118 mIU/L (Post meno-21.7-153)
LH - 49.5 mIU/l (Post meno-11.3-39.8)
Cortisol - 475 mmol/l (138-690)
Fasting C-peptide- 1.7 ( 0.8-2 )

27.  USG :
Fatty change in Liver with Hepatomegaly
03/06/13:
Liver is mildly enlarged in size,paranchymal
echogenicity is increased.
ECG :
Sinus Tachycardia with Complete RBBB

28.  Type-1 Diabetes mellitus Autoimmune
 Primary Hypothyroidism polyglandular
 Premature Ovarian Failure(POF) syndrome- ll
 Mucosal vitilligo
 Dyslipidaemia
 Hypertension

29.  Whether patient having Type-1 DM or Type-2
DM?
 How can we confirm Type-1 DM ?
 Is it necessary to confirm Type-1 DM to put this
case under APS-ll ?

30.  Patient
 Prof.Farid uddin
 Asso.Prof.Dr. M.A. Hasanat
 Dr.Yasmin Aktar
 Dr. Md. Jaki yamani abirDr. Md. Jaki yamani abir
 Dr.Showrab Biswas

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